Banana Splits Signup Form

Banana Splits Support Group Signup Form-Via Email

Welcome Parents,

To use this form to sign your child up for the next Banan Splits Support Group, please follow these steps:

Copy the entire form below. (How? Left click and scroll over entire Form, then right click, and choose copy)
Next, Click this link > Email Form To Kevin Lee.
Paste the form into the email that will open addressed to Kevin.
After you copy it to your email, complete the form. ☺
When the form is completed, send it to me!

After you send the Form using email, this page reappears. You're done! I will send you a note within a few days indicating that your signup form has been received. Thank you.

Kevin Lee, Youth Advocate

↓ Copy Form ↓ ↓ Copy Form ↓ ↓ Copy Form ↓

Banana Splits Signup Form
(All Information is Confidential)

Child’s Name: _____________________________________Age: ___Grade: ___DOB: ___/___/___

Address: ________________________________________________________________________
Street Apt. # Town Zip Code

Home phone: _____________________Work:____________________Cell:____________________

Email Address: ____________________________________________________________________

School attended: ___________________________________________________________________

Custodial Parent’s Name: ____________________________________________________________

___Separated from child’s other parent How long? _______

___Divorced from child’s other parent How long? _______

With whom does your child live? ___________________________________

In case of illness or emergency during group time, whom should we call if we cannot reach you?

Name: ___________________________________________Phone: ________________________

Relationship with your child: _____________________________________________________

Text Box:
Non-custodial Parent’s Name:
______________________________________________________
(If applicable)

Frequency of visitation: ___none ___occasionally ___monthly ___weekly ___2x weekly

Additional helpful comments: _______________________________________________________

____________________________________________________________________________________

Is there any additional information that would help us to support your child during group time? _________________________________________________________________________________

_______________________________________________________________________________________

Today’s date: ___/___/___